Can your ASC meet the credentialing challenge of new tools, techniques?
Can your ASC meet the credentialing challenge of new tools, techniques?
Design process to handle change
Laparoscopic Nissans, endoscopic carpal tunnel repair, and intrauterine balloons to treat menorrhagia are only a few of the newer surgical techniques seen in ambulatory surgery programs today. Some new procedures don’t require extra training for the surgeon to acquire competence while other procedures do mean additional training and even proctoring to ensure competence before the first surgery.
How does an ambulatory surgery program manager make sure surgeons are properly trained and competent? The key to knowing patients are safe and your program is not exposed to undue liability is the credentialing process that grants surgeons specific surgical privileges, experts say.
"There are a number of different ways to organize privileges," explains Jack Zusman, MD, a professor at the University of South Florida in Tampa, who specializes in medical staff operations, credentials, and privileges. "Years ago, hospitals used to just give whatever privileges the surgeon requested by checking off items on a surgical laundry list produced by the hospital or its surgery center." Now, surgeons have to document training and experience, so it is rare to find a surgeon asking for privileges outside his or her area of specialty, he points out.
The simplest way to organize privileges is to set up core privileges that cover all surgeries that involve the same skill sets, says Zusman. For example, hand surgery could be used to grant privileges for any surgery involving hands, such as tendon repair or biopsy. "Privileges for an ambulatory surgery program would differ from an inpatient surgery program because you would not want a surgeon reattaching a finger in an outpatient setting," says Zusman. For this reason, the medical staff bylaws or a policy attached to the privileges need to explain clearly which procedures are allowed within the operating rooms. This is especially important for ambulatory surgery programs that are affiliated with or located within a hospital, he adds.
Review existing guidelines
One way to start developing new privilege guidelines or reviewing existing ones is to refer to credentialing guidelines that have been recommended by other groups.
"There is no reason to reinvent the wheel," says Steven D. Wexner, MD, chief of staff for Cleveland Clinics Florida in Naples, and chairman of the credentialing committee for the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) in Santa Monica, CA. "Not only does SAGES have guidelines, but other medical societies have developed them as well."
Referring to guidelines developed by different medical societies can be a good starting point, but you need to be aware that some turf battles are being fought, says Zusman. "Guidelines for a society that includes plastic surgeons may exclude maxofacial surgeons, dermatologists, otolaryngologists, or general surgeons from performing certain procedures because [the organization doesn’t] want to give up these patients," he explains. For this reason, Zusman recommends reviewing a variety of guidelines from different societies with an eye toward finding which approach works for each individual outpatient surgery program.
The best way to evaluate or update your credentialing process is to talk with peers, says Zusman. "Find out how the outpatient surgery program down the street or in the next community handles credentialing."
New’ presents problems
Even if an ambulatory surgery program has a good process in place for awarding privileges, new technology and new surgical techniques can pose problems.
Laparoscopy once presented a credentialing challenge, but it is not as much of a problem as it used to be. "When laparoscopy first came into use for more than gynecological surgery, we had general surgeons who had never been trained. They had to take CME courses, practice on animals, and perform several cases with a proctor. Now, most surgeons receive laparoscopic training in their residencies," says Doug Yunker, MD, medical director at Upper Arlington Surgery Center in Columbus, OH.
If a surgeon asks for laparoscopic privileges, it is important to make sure he or she is competent with the open procedure, says Wexner. "With Nissans or cholecystectomies there is always the chance that the procedure has to be converted to an open procedure, so you need to make sure the surgeon can handle the open procedure," he adds. If the surgeon has been performing the open procedure and wants to add the laparoscopic technique, another surgeon with the laparoscopic privileges should proctor the first few procedures, says Wexner.
The number of cases that should be proctored for any new procedure is hard to determine, he says. There is a debate about how to determine the right number, so the trend is not to use numbers but to let the proctor evaluate the surgeon’s competence. For some surgeons, this may mean two procedures; for others, it may mean more, he adds.
Endoscopic carpal tunnel repair, operative laparoscopy, and laser surgeries do require proctors for surgeons first applying for the privileges in his surgery center, says Yunker. "If they received training within their residencies, we waive the proctor requirement, but the surgeons have to show proof that they were trained in the specific procedures for which they are applying," he adds. Surgeons also have to document that they have been trained on the specific lasers that they intend to use in the procedures. Proof of training can consist of a letter from the surgeon’s school at which the residency was served.
In addition to showing proof of training, surgeons at Yunker’s facility have to show that they have performed the procedure at least twice in the previous year. This proof involves patient names, case numbers, and locations if the procedure was performed elsewhere.
When the issue is a new tool, such as the intra-uterine balloon, surgeons with privileges to perform a hysteroscopy only have to receive training on the machine from the manufacturer’s representative, says Yunker.
"Usually, the manufacturer’s representative attends a procedure and demonstrates how to use the equipment," he adds.
Manufacturers’ demonstrations are adequate for most new equipment unless the equipment requires extra knowledge or skill to be handled safely, says Wexner. "Lasers or radiation used in surgery require extra credentialing to address safety issues."
While manufacturers’ training is useful and can properly train the surgeon and nursing staff on the use of new equipment, the representatives’ presence in an operating room does raise questions of liability, points out Zusman. "If a manufacturer’s representative is in the operating room, the patient needs to give consent. From a risk management point of view, this is important," he explains.
If the issue is a new technique, a committee such as a credentialing committee must review the proposed procedure. In addition to documenting whether the procedure will be allowed, the decision-making process itself must be documented, says Zusman. (See article on documentation, above.)
Even when a surgery program has a solid credentialing process in place, Zusman has seen some organizations exposed to liability risks by ignoring the process.
"The most common way an ambulatory surgery program manager or physician ignores credentialing requirements is when a visiting surgeon who is a recognized expert, or even a family member who is a surgeon performing a new procedure in his or her hometown, is allowed to demonstrate new procedures to the program’s medical staff," he says.
"Physicians may think they know this visiting surgeon’s qualifications, but unless there is some reference check and documentation of the surgeon’s experience or training, the surgery program manager places the facility at great liability risk," Zusman says.
Another critical piece of the credentialing process is reappointment. "Physicians should be reappointed every two years," says Zusman.
Evaluation of the physician during the reappointment process should include a review of cases to show at least two of each of the procedures for which the physician has privileges and any morbidity and mortality reports that apply to the physician, adds Yunker.
"There are no national credentialing guidelines that can be applied to each and every surgery program," says Zusman.
"Each ambulatory surgery program manager needs to look at what the market demands, what surgeons in the area are doing, and what the facility’s physical configuration and staff can handle to design an effective credentialing process."
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